Pediatric Heart Failure Guidelines
II–IV) with a resting heart rate ≥70 bpm and are either on a maximally β-blocker dose or
β-blocker is contraindicated.
• Side Effects: include fetal toxicity, atrial fibrillation, bradycardia, sensitivity reactions e.g.
angioedema.
• Special Considerations: Bonnet et al. J Am Coll Cardiol 2017;70:1262–72
Calcium Channel Blockers (Non-dihydropyridine)
The non-dihydropyridine calcium channel blockers act upon the peripheral calcium channels as
well as the calcium channels in the myocardium decreasing inotropy and chronotropy.
Therefore, they are typically avoided in pediatric heart failure, but can be utilized in hypertrophic
cardiomyopathy. Diltiazem is the principle drug used.
• Indications: Hypertrophic Cardiomyopathy
• Side Effects: include dizziness, 1 degree AV block, edema, bradycardia, hypotension
st
& vasodilation.
• Special Considerations: Should not be used in patients with WPW; Avoid use in
patients with systolic heart failure
Digoxin
Digoxin causes inhibition of the sodium/potassium ATPase pump in myocardial cells results in a
transient increase of intracellular sodium, which in turn promotes calcium influx via the sodium-
calcium exchange pump leading to increased contractility. May improve baroreflex sensitivity.
There is retrospective data suggesting improved outcomes in patients between Stage 1 and
Stage 2 palliation of single ventricles and the post-hoc analysis of prospective data (The Dig
Trial) showing decreased hospitalization and decreased mortality in patients with lower digoxin
levels. Controversy continues to exist despite being in clinical use for almost 250 years!
• Indication: include symptomatic ventricular dysfunction. Digoxin may also be used in
SVT and other arrhythmias with the input of EP.
nd
st
rd
• Side Effects: include heart block (1 , 2 and 3 degree), ST segment depression, atrial
tachycardia, anxiety, dizziness, headache, blurry or yellow vision, vomiting, nausea, and
diarrhea.
• Special Consideration: Digoxin has a low therapeutic index, monitoring for side effects
should occur frequently and include routine ECG evaluation. In the setting of suspected
or confirmed acute digoxin toxicity, patients may be treated with Digibind (see table).
Diuretics
Loop (furosemide, bumetanide) and thiazide (Chlorothiazide, Metolazone) diuretics are used to
treat congestive heart failure. Adult studies indicate that diuretics do not improve outcomes in
heart failure. However they may be helpful in reducing heart failure congestive symptoms.
Given in combination they act synergistically. Tolvaptan is a vasopressin antagonist and is
useful when the serum sodium is low.
• Indications: congestive heart failure
• Side Effects: include uremia, hypokalemia, renal Insufficiency, kidney stones.
• Special Considerations: renal insufficiency from spironolactone and ACE-inhibitors can
be exacerbated with diuretics
Updated 7/31/2018 page 10